J96.92 — Respiratory failure, unspecified with hypercapnia
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Each claim must be submitted with ICD-10-CM code(s) that accurately reflect the patient’s condition and indicate the reason(s) the service was performed.
- The medical record must include the ordering/referring provider’s name and NPI for services that require a referring/ordering physician.
- The patient’s medical record should include the assessment by the ordering provider related to the patient’s complaint, relevant medical history, results of pertinent tests/procedures, and signed and dated office visit or operative reports.
- For diagnostic tests, report the test result on the claim when known; otherwise report the symptoms that prompted performance of the test.
Key Coverage Criteria
- Cardiac catheterization and coronary angiography are covered when the medical record documents medical necessity, including relevant medical history, physical examination, and results of pertinent diagnostic tests that support the procedure.
- Therapeutic procedures whose principal aim is to treat a respiratory impairment must be billed using HCPCS codes G0237, G0238, or G0239.
- Monitored Anesthesia Care (MAC) is medically necessary when the patient has one or more documented diagnoses listed as supporting medical necessity (e.g., F91.9, G97.81, T81.9XXA, T88.8XXA, F79) and the diagnosis is matched to the anesthesia/CPT/HCPCS procedure performed.
- Use G9 anesthesia modifier to indicate need for MAC due to a history of severe or advanced cardiopulmonary disease when the proceduralist determines additional monitoring is required.
- Use G8 anesthesia modifier for certain deep, complex, complicated, or markedly invasive surgical procedures when applied to anesthesia codes 00100, 00300, 00400, 00160, 00532, or 00920.
- MAC may be appropriate for pediatric patients (Medicare-eligible and younger than 18) when documented using ICD-10-CM code T88.8XXA and clinical records justify the need for MAC.
20 Active Policies
L35434 — Oximetry Services
J12
A57361 — Billing and Coding: Monitored Anesthesia Care
J12
A57205 — Billing and Coding: Oximetry Services
J12
L35049 — Monitored Anesthesia Care
J12
AETNA-CPB-0650 — Polymerase Chain Reaction Testing: Selected Indications
Related Codes
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